Cultural Child and Adolescent Psychiatry

G. Pirooz Sholevar

Introduction

Cultural child and adolescent psychiatry consists of a body of theoretical and technical knowledge that informs high quality psychiatric evaluation, treatment and assessment of developmental process across cultural and language barriers to children, adolescents, and families. Clinicians are increasingly called upon to evaluate or treat patients from multiple cultural and linguistic groups. In our multicultural American society, treating a patient who speaks a different language or holds beliefs at variance with the majority culture requires the knowledge and skills that constitute cultural psychiatry (1). Cultural psychiatry defines the impact of culture on psychiatric evaluation and diagnosis and provides guidelines for culturally competent and sensitive psychiatric treatment and systems of care (1,2,3). It is characterized by introducing the vast diversity of human experience into an understanding of the complexities of mental health and illness.

Cultural psychiatry has evolved consistently throughout the past century. Initially and at the beginning of the twentieth century it was primarily concerned with comparison of manifestations of mental disorders in different cultures and countries. It described the exotic and special features of different syndromes and disorders discovered in Africa, the Far East, and other non-Western countries. The descriptions were based on a universalist (and Western) viewpoint of psychiatry and mental disorders. In the mid-twentieth century prominent anthropologists such as Ruth Benedict, Margaret Mead, and Bronislaw Malinowski incorporated psychoanalytic constructs into their cultural investigations of the impact of culture on personality development and disorders (4). This highly productive collaboration between psychiatry and anthropology also included Emile Durkhiem’s landmark study on suicide and George Herbert Mead’s Symbolic Interactionalist Theory.

The interest in sound methodological measures in the mid-twentieth century resulted in the construction of a number of crossculturally validated epidemiological and diagnostic instruments. Recent findings based partially on such methodology have resulted in a gradual shift from a universalist viewpoint to a more culturally specific perspective (1,2,5).

The value orientation theory was originally proposed by Kluckhohn (6). It is based on variations in generalized cultural values. According to Kluckhohn, there are three possible variations in solution to the problems of time (past, present, future); activity (doing, being, being-in-becoming); relationship in groups (individual, collateral, linear); man–nature relationship (harmony-with-nature, mastery-over-nature, subjugated-to-nature); and basic nature of man (neutral/mixed, good, evil).

Cultures vary widely in these dimensions. For example, American culture emphasizes a future time orientation, a “doing” mode of activity, an “individualistic” relational orientation focusing on autonomy; mastery over nature; and the nature of man as neutral or mixed. Using this now-dated typology, Spiegel (7) pointed how Southern Italians in contrast are oriented toward present, being, collateral relational view, subjugation by nature and a mixed view of human nature, while Southern Irish are oriented toward present, being, lineal relationships, subjugation by nature and the evil nature of man. In their views, the contrast between variable value orientations can create interpersonal tension and conflicts, such as in a crosscultural marriage.

The cultural relativist perspective of current cultural psychiatry is in contrast to the universalist one, and asserts that cultural values and meanings are relative to and embedded in their cultural context and cannot be measured against a universal system. It uses locally meaningful categories to describe indigenous syndromes, their phenomenology, and native explanatory models based on an ethnographic perspective (8). They make strong attempts to avoid the categoricalfallacy.

Category fallacy refers to application of a category that is valid within one cultural context to a culture where the category has no diagnostic validity or relevance. It stems from a universalist approach to assigning meaning to behaviors transculturally. In contrast, cultural relativists propose that cultural meanings and values are relative and fundamentally embedded in their cultural context. The latter perspective is referred to as emic, in contract to the former approach, known as ethic, which applies Western diagnostic categories to another cultural context (8).

Definitions

Culture consists of those patterns of behavior, acquired and transferred over time, which prescribe the norms, customs, roles, and values inherent in political, economic, religious, and social aspects of family life. Culture provides the set of rules and standards that guide people’s actions, makes their behavior understandable to one another, and helps to explain individuals’ relationships to their sociobiological context.

Ethnicity refers to the sense of belonging and having a rootedness in history that reaches beyond religion, race, or national or geographic origin. Ethnicity is our basic identity—who we are in relation to other human groups. It frames our manner of dress, style, and communication through language and rituals, as well as how we feel about life, death, and illness (9,10). The concept is derived from the Greek work ethnos, or people of a nation. We are born with an ethnic identity. Throughout life we experience and adopt different cultures, thereby living with expectations and values from both a majority culture (i.e., the American culture) and minority culture—our culture of origin. We carry with us both the values, assumptions, traditions, and worldviews transmitted over generations within our ethnic group and the concurrent—sometimes competing—view of the cultural
context in which we live. As noted by McGoldrick et al. (10) and Herr (11), ethnic traditions still affect third and fourth generations in subtle ways and are often experienced as cultural conflicts between members of the younger generation.

Cultural context refers to the sociocultural environment in which people live and interact. The combination of ethnic origin and cultural context, together with the pressures imposed by cultural transitions and/or migration, inevitably creates difficulties that family groups must resolve. Landau (12) discusses the challenge minorities face in balancing the demands of living within two cultures—the culture of origin and the majority culture. She notes that if the stresses and differences are too great, the family network is too remote or too weak to help, the family must either adapt to the culture or turn inward on itself, becoming isolated and enmeshed as a family group. As a consequence of the ethnocentric defense, very often the family resists accepting help from outsiders unless their problems become too great to handle alone.

Cultural identity refers to the patient’s cultural or ethnic reference group and the degree of involvement with both host culture and culture of origin. This internalized self-definition selectively incorporates values, beliefs and historical elements from those available in the person’s environmental values and contains self-experiences related to ethnicity, gender, values, and a wide range of beliefs.

Ethnic identity describes a sense of commonality transmitted over generations by the family and reinforced by the surrounding community (10). An ethnic group is defined as “those who conceive themselves as alike by virtue of their common ancestry, real or fictitious, and who are so regarded by others” (13). It is perceived as “we” in contrast to “they.” Ethnic identity develops as the product of ethnic socialization by children acquiring the values, attitudes, behaviors, and perceptions of an ethnic group, and perception of themselves and others as members of the group (14).

Cultural mask, Montalvo and Gutierrez (15), refers to the family’s use of real elements in their culture to conceal their problematic behavior and interactions. For example, the family can use the rationale: “We are Latin, we are expected to have hot tempers.” The family thus uses culturally sanctioned behavior in a defensive fashion in order to protect crucial underlying issues. The family presents to the therapist a view of who they are based on what they think is expected of them instead of showing how they actually behave when trying to resolve problems or even interact with one another. Montalvo and Gutierrez caution the therapist to search for the problemsolving approach of the family and not get caught up in exotic or unusual behavior patterns unique to the family’s culture.

Acculturation

Acculturation refers to the process of behavioral and attitudinal changes in a cultural subgroup as a result of exposure to the practices of a different dominant group (16). Initially it was hypothesized that a high level of acculturation decreases stress and the risk of psychological disorder in members of cultural subgroups. Subsequent studies have further recognized the complexity of the process; the concurrent relationship between a high level of acculturation and increased psychological distress probably due to social role conflicts and the partial loss of traditional support received from the original culture (1,17,18).

The culturally sensitive clinician can be well served by paying close attention to the unique experiences of each individual in the acculturation process as it is manifested by intense rejection or blind acceptance of cultural elements of the host or original cultures, or a defensive resistance to assimilation into the broader culture. The complexity of the acculturation process in child/adolescent and family psychiatry can be significant because of different levels of acculturation achieved by children and their parents. Children born in the host country can achieve a very high level of acculturation, while parents may adhere strongly to the practices of their original culture and reject the values of the host culture. Fathers may develop a much higher level of linguistic and cultural competence due to their workplace experiences in contrast to the mothers, who may not learn the new language and cultural practices if primarily functioning in the household. The level of acculturation of younger children may also differ significantly from that of older children, particularly if born and initially raised in the previous culture and exhibiting sharp differences from their younger and Americanized siblings.

The degree and nature of the acculturation process can be determined by inquiry into age at immigration, number of years in the United States, language proficiency, and participation in the host culture’s social activities and social networks (1,16).

Culture-Bound Syndromes

Culture-bound syndromes consist of disturbances in mood, behavior or belief systems that appear restricted to a particular cultural context. They are frequently viewed as exotic or covert illness phenomena occurring in the context of a local culture. Many culture-bound syndromes have been described worldwide. For example, some syndromes can exhibit acute episodes of anxiety, such as ataques de nervios in Latin America or Koro in Malaysia. The former syndrome manifests by trembling, shouting, crying, fainting, seizure-like activity or suicidal gestures. The person may return to normal functioning rapidly. As with many similar syndromes, it is a pattern of behavior that is understood locally as a meaningful manifestation of distress, acceptable within the cultural context. Such symptoms signal distress and activate a culturally specific response to the situation. The symptoms are recognized and interpreted through the appropriate attribution, which is part of the common socialization process for the cultural subgroup (8).

Effect of Culture and Ethnicity on Child Development

Recent trends have brought the cultural context of child and personality development into bold relief. Among these are the global demographic trend toward cultural heterogeneity, and contributions from crosscultural psychiatry and psychology. It is generally established now that culture influences the development of children and shapes personality from infancy through adulthood. The childrearing practices of parents and family provide the infant with the basic nurturance needed for development. Equally important is the role of parents and family in transmitting cultural rules, standards, and values to the child through the process of socialization. Cultures vary widely and differ from each other in the way the tasks of socialization are carried out, the specific rules and values transmitted, and the behavioral and conceptual outcome of socialization process in terms of beliefs and world views adopted by the children (19,20,21).

It is also firmly established that much of our information on child development is based on norms that are almost exclusively Western, middle class and male oriented. Most of the observations and studies have been conducted in Western settings and are nonrepresentative of the world’s population. These studies perpetuate a given view of the universe and tell
us little about how children develop in so-called “minority cultures” in Western societies (22,23). Child rearing practices vary widely in different cultures. In many cultures, particularly Western ones, the main parenting person is the mother, with the father assuming an important but secondary parental role. In African societies, older siblings assume a significant role in raising infants and young children. Other family members and grandparents assume important childrearing roles in Asian and some other countries. Other caretakers offer the children a different or expanded view of the world (24,25). Socialization occurs not only through explicit teaching but also through day-to-day experience of childhood and through the structure of the settings where the children live and play.

Cultural Impact on Developmental Stages

Examination of influence of different cultures on different developmental stages is gaining intense interest among investigators. We briefly review the investigations of several developmental stages.

Crosscultural Research on Infancy

A strong theme in literature is the “precocity” of babies from traditional, nonindustrialized societies. They may stand or sit two to four or more weeks earlier than American and European norms. At times the precocity in Africa has been linked with reports of precocity at birth. The clusters of advanced behaviors are to a large degree correlated with environmental factors (26,27).

Putting aside the multiple and complex methodological shortcomings in many studies, it is generally established that African babies reared in relatively traditional ways achieve many motor functions, particularly in the first year of life, before their European and American counterparts. The findings from studies in Uganda have been subsequently supported by multiple studies in other African Countries (26,27). The advanced skills frequently coincide with deliberate teachings of the infants by the mothers and other caretakers of how to walk, sit, and help the babies practice those skills. They may use props to facilitate those tasks. The encouragement of sitting and carrying the baby on the caretaker’s back is more helpful in the development of trunk, buttocks, and thigh muscles in comparison to having the child sit on an infant seat (26,27,29). Similar findings have been reported in Asian countries, including India (28,30).

Lester and Brazelton (31) propose that African childrearing practices are built on the infant’s responsiveness to being handled in the neonatal period and facilitate motor precocity. Motor excitement of infants may elicit intense interpersonal handling from the caregiver, thus enhancing developmental progression. Normal infants in different traditional cultures appear to exhibit critical cognitive developmental levels at about the same time throughout the world (26,31).

Temperament

In studying temperament, cultural affiliation is a strong predictor of infant temperament in the first year of life and is exquisitely sensitive to environmental influences. McDermott (25) has proposed that temperament should be viewed as a constellation of traits with a threshold of expression that varies from culture to culture. Considering two broad clusters of temperament, namely rhythmicity and activity, significant cultural variations are evident. Chinese American, Japanese American, and Navajo Indians are temperamentally less excitable than other groups who exhibit lower levels of arousal and are easily consoled. Mexican Indians and Kenyan infants have smoother transitions from one state to another and maintain quiet, alert states for longer periods and are higher on motor maturity (25,32,33).

Examining the investigations of Jerome Kagan (34,35) on shyness and social/behavioral inhibition, McDermott (25) proposed that cultures impart meanings to the behavior but also determine how others perceive and react to the behavior. Inhibited and shy children are more readily accepted by mothers in the Chinese culture, as opposed to the North American. Shy-anxious children in China are valued and accepted by society and peers and adjust well to their social environment (34,35,36). In the West, shyness and social withdrawal are associated with peer rejection and isolation, reflecting strong emphasis of the West on the need for self-expression and self-confidence (34,35,36). In contrast, the ready acceptance of this biologically determined behavior by parents, teachers, and peers in Asian culture reflect a low level of apprehension about this trait. McDermott proposes that Chess and Thomas’s model of goodness-of-fit be applied at the cultural as well as the individual level.

The first large-scale investigation of children living in multiple cultures was undertaken by the anthropological team of Beatrice and John Whiting (37,38). They compared the behavior of children and the adults’ expectation of them in six different cultures: India, Kenya, Mexico, Okinawa, Philippines, and the United States. Children in nonindustrialized cultures were given tasks important to the well being of the families, such as caring for younger siblings and tending to a goat so the family did not go without milk. Children showed nurturing and responsible behavior. Children in industrialized cultures were not expected to contribute to their family’s survival, were more self-centered and dependent, and their self-centered orientation was tolerated by their families. The self-centeredness may be actually an asset in Western cultures and enhance the desire for personal profit (19). Whiting and Whiting found the influence of peers on young children to be very powerful and occur early. Additionally, parental efforts to control and redirect the aggression of their children emerged more strongly than their nurturance in all of the above cultures (25,37,38).

Being part of a group, rather than individual assertiveness, is highly valued in many cultures. Being agreeable, respectful, emotionally mature, courteous, and self-controlled are considered major assets as they promote interdependence. Traditional Japanese culture views newborns as independent and making them dependent, bound to and part of the group, is considered a fundamental task of the family. The Japanese traditional practice of keeping young children close to the mother all the time fosters a high level of social and personal closeness and interdependence characteristics that are very different from American culture (19,39).

Preschoolers

Preschool Chinese children are expected to pay close attention during lessons, unlike American preschoolers. Chinese nursery school teachers initiate and organize most of the daily activities, while the children listen, follow directions, take turns, and share. The activity structure teaches the children the value of self-control, obedience, and cooperation with other children. In contrast, the American nursery school provides a wide range of toys that can be used by children in their own way in free play, transmitting the importance of self-expression and individuality in the American culture (19,39).

Children’s inclination to compete or cooperate emerges as a signification differential point among Anglo-American and many non-Western or nonindustrialized cultures. Madsen used a cooperation game for two players, where only one child could partially win if s/he cooperated with the other person but both children lost if they competed. Madsen (35,41) found dramatic behavioral differences between urban
Anglo-American and rural Mexican children. The Anglo-American children, particularly the older ones, were far more competitive even when it did not benefit them. The rural Mexican children were far more cooperative, even when they did not directly benefit. The strategies of both groups of children were adaptive within their culture (19).

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